Transcript Slide 1
Management of Post Menopausal bleeding Dr Matt Hewitt PMB • 1 year after cessation of periods • 10-15% chance of endometrial cancer • 90% or endometrial cancers present with PMB • Requires immediate assessment • If referred should be classified as urgent • (Persistent vaginal discharge) Causes of PMB • • • • • • • • • Atrophic vaginitis Endometrial/cervical polyps Endometrial cancer Cervical cancer Vulval/Vaginal cancer Endometrial hyperplasia Vulval sin disorders Prolapse Ovarian/fallopian Ca • Anal rectal tumours • Bladder pathology Endometrial cancer Risk factors • Obesity • Unopposed oestrogen • Polycystic ovarian disease • Nulliparity • ↑ age Prognosis • Presents early • Curative treatment likely Endometrial cancer • • • • • PMB <50 years1% risk PMB >80years 25% risk Obesity 18% risk Diabetics 21% risk Obesity and diabetic 29% risk Ultrasound scan • • • • • Transvaginal if possible Endometrial thickness <4mm or <5mm Irregular endometrium Fluid within cavity Inability to see endometrium US of the endometrium U/S and endometrial cancer • Sensitivity of 96% • Specificity 39%- 50% • Possible increase sensitivity with endometrial sampling PMB or Persistent vaginal discharge Examination Normal Abnormal U/S scan Endometrial thickness <5mm Endometrial thickness >5mm Bleeding persists Refer No Yes Consider referral D and C Obese/elderly Hysteroscopy Polyp Atrophy Other Remove Consider Vagifem Rx Refer appropriately D and C Hysteroscopy If bleeding persists despite normal scan refer If bleeding persists after hospital investigation re -refer Tamoxifen • Increased risk of endometrial cancer 3 to 6 fold • No evidence for routine screening • Therefore PMB and Tamoxifen requires referral Thickened endometrium in asymptomatic women • No trial has yet been done • Data from UKCTOCS • 5mm endometrial thickness sensitivity 77% specificity 85% • Indicates possibility of value of screening • Refer! PMB and HRT requires investigation when Sequential regimens • If heavy or prolonged after end of progesterone phase • Break-through bleeding Continued combined regimes • Bleeding after first 6 months of commencement of treatment • After amenorrhoea has been established www.corkwomensclinic.ie